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San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a "Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act% the following <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week, transports less <br /> than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6, and the <br /> generator or parent organization has on rile one of the following: <br /> 1- Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small <br /> quantity generator required to register pursuant to Chapter 4. <br /> Information Document if the generator or parent organization is a small quantity generator not uired to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH S67fr=gW <br /> )D- C F <br /> San Joaquin County Public Health Services F—CEN/ L <br /> Environmental Health Division APR 19 '19% APR 1 <br /> Medical Waste Management Program <br /> 304 E Weber Ave ENVIRONMEN HEALTH MM <br /> Stockton, CA 95202 pFRP�i.T 1 SERVICES <br /> Medical Waste Hauler Information <br /> New 0 Renewal n '1 <br /> Medical Office/Business Name: C1./nJ1cAl; J tE'AL-rg4Ph'RArSAGS --r NC <br /> Medical Office/Business Address: 7//,_I/ 5T <br /> City: SArd a 14f NTt� Staters R _up Code: <br /> Contact Person: kr 27Ta Phone <br /> Storage Facility Name: ('LLqA, --U A P ERA i r aj. <br /> Storage Facility Address: <br /> City: r7ACRl` MrLA�n State: A Zip Code: <br /> Permitted Treatment Facility Name: ,r MgclikeAL --9,Y,UX <br /> Permitted Treatment Facility Address: 7 7 c Ro c <br /> City: Rail n i 'e r-do va _State: l'A Zip Code: S( 70 <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: Title: Pr,Ss dGn�- <br /> 2- Name: Br f .ScyarLcn Title: Bil.A rca 171a na a �r <br /> 3- Name: Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. in <br /> addition, all copies of medical waste records shall be kept on file at generators or health care professional's facility. <br /> Applicant Signature:.�� <br /> _ ��tTA_rla �tr�[rt/ Date: 4 / / e / 9 q <br /> Title: - <br /> Do Not Write Below This Line <br /> 1,vJ. 05s,� 73 <br /> Approval, ` ( Date: S�Expiration Date: 42/3/ <br /> R.E.H.S. Application App 1 <br /> V EH4502 10-03-96 Date Paid l / / Cash or Check(circle) Acca <br />